There is a growing acceptance in Australia that greater transparency around staffing numbers will become part of the aged care landscape in the future. The country’s largest peak body for aged care providers has switched its opposition to ratios to support for a new concept: ‘smart ratios’.

The pandemic has exposed the weaknesses in our aged care system, leading to rethinking of past practices and reconsidering of the future.

More than 2,000 aged care residents have contracted COVID-19 and tragically nearly 600 residents have died. Though Australia has done better than some countries in protecting its older citizens, it is still a disaster of immense proportions. 

Lack of infection control skills made pandemic worse in aged care

A shortage of aged care staff with in-depth knowledge about infection control weakened Australia’s response to COVID-19.

If Australia had had greater numbers of more-qualified staff working in aged care homes during the crisis, would the outcome have been better?

We have known for a long time that aged care facilities were short staffed and did not have enough highly qualified staff; these inadequacies have had tragic consequences during the pandemic.

In the Royal Commission into Aged Care Quality and Safety’s hearing about the sector’s response to COVID-19, counsels assisting Paul Bolster and Peter Rozen QC wrote of the “deficits flowing from the absence of skills related to infection control” among staff in aged care facilities.

Staff ratios on royal commission’s agenda

The royal commission’s final report, due in February, is likely to include recommendations relating to staff ratios. They may recommend ratios be mandatory, or that providers reveal greater transparency about staffing numbers and skills, or perhaps the requirements will fall somewhere in between.

In hearings in late February, counsel assisting the royal commission, Peter Rozen QC, recommended that aged care providers “should be required by law to have a minimum ratio of care staff to residents working at all times. 

“The ratio should be set at the level that is necessary to provide high quality and safe care to the residents in its facility.”

The pandemic has only made a recommendation along these lines more likely.

Tentative steps

HelloCare has reached out to a range of industry peak bodies, leaders and experts and asked if they support mandated staff ratios or greater transparency around worker ratios in aged care facilities, and if their views have altered during the course of the pandemic.

We found there has been some movement on the issue. The industry is taking some tentative steps towards acceptance of staff ratios in aged care.

Here are the comments we received.

Sean Rooney, CEO, of Leading Age Services Australia
Supports ‘smart’ ratios, position updated

“LASA believes that we should be able to design ‘smart’ ratios that are case mix adjusted, aligned to care outcomes, linked to funding, and allow flexibility to adjust to local circumstances, on an ‘if-not-why-not’ basis. 

“That means, if the provider’s staffing numbers and skills mix are not consistent with the agreed case mix requirements, then they must detail why not and what is the impact on the care outcomes delivered.

“LASA has long supported increases in overall staffing levels in aged care facilities – our sector tells us they want more staff, who are well-skilled and well-paid. The challenge is that the average provider is struggling to cover their current operating costs.

“LASA has historically had reservations about a simple ‘one size fits all’ ratio because there is a range of factors that influence the best approach to determining the right number and mix of staff in a residential care service, including acuity and care needs of residents, models of care employed, the layout of facilities, the age of facilities, and rural and remote workforce issues.

“There is a diversity of care need scenarios that need to be accounted for in staffing decisions. Operational management within a facility needs to retain some flexibility to make staffing roster decisions relative to changing resident acuity and care needs, consistent with the organisation’s governance and human resourcing requirements, and that meet Aged Care Quality Standards.

“The Productivity Commission in their 2011 ‘Caring for Older Australians’ report described a minimum staff to resident ratio as a blunt instrument.  Furthermore, the Aged Care Workforce Taskforce in their ‘A Matter of Care’ report (2018) did not support a mandated minimum staff to resident ratios. They sought to conduct research into flexible models that realised holistic care and quality of life outcomes, rather than a singular focus on clinical outcomes.  

“LASA contends our sector needs to have more staff, they need to be more skilled and qualified, and they must be appropriately remunerated. 

“The challenge for the sector is how we achieve this.”

Rodney Jilek, managing director, Aged Care Consulting and Advisory Services Australasia, who has been working in Melbourne aged care homes with outbreaks over the last fortnight
Supports staff ratios, in combination with other measures

“While I still believe transparent minimum staffing ratios are one element that is required, COVID-19 in Melbourne has taught us that mix is just as important. If the site doesn’t have appropriate clinical governance frameworks supported by qualified staff it all ends in disaster.”

Joseph Ibrahim, Professor and Head of Health Law and Ageing Research Unit at the Department of Forensic Medicine, Monash University
Supports greater transparency around staffing levels 

More transparency around staff ratios “can be done now and should be done immediately as it informs residents and families. They have a right to know.

“It creates the environment for the issue to be closely examined, debated and new ideas

But staffing issues in aged care go “beyond just the numbers”. Professor Ibrahim said we should be training specialist clinicians to care for older Australians.

“We need specifically trained and qualified staff, possibly a new profession for aged care that combines a bit of medicine, nursing, allied health into a specific person.

“Our thinking is so 20th Century and we need to review what residents need, then the skills to deliver that, then staffing levels.”

Mandated staff ratios is a “tough” issue.

“There is substantial variation in the resident’s clinical profile, therefore a ratio may create over and understaffing.

“We do not have a generic model of aged care services. We do not have a clearly stated purpose for an aged care facility: [is it] rehab, chronic disease management, or lifestyle?”

Minister for Aged Care, Richard Colbeck
Does not support staff ratios, position unchanged 

“The Royal Commission into Aged Care Quality and Safety is considering key issues around workforce and the Australian Government will respond to its findings when they are delivered in February.

“Commonwealth regulation does not prescribe the qualifications required by staff, nor the number of staff required to be employed by an aged care service, however it does set out instances where a registered nurse is required, for example in assessment and care planning, and in the delivery of complex nursing procedures.

“Providers of residential aged care are required by law to meet Aged Care Quality Standards to ensure quality care and services are provided to all aged care residents regardless of aged care provider type. 

“The Quality Standards require organisations to have an effective and competent workforce where each staff member has the appropriate qualifications and knowledge to perform their role.

Aged care homes are expected to consider the different levels of skills and abilities needed to meet residents’ needs.

“Providers are expected to regularly review workforce levels and mix of skills of their staff, and adapt these to respond to the changing needs and situations of care recipients.

Julie Collins, Shadow Minister for Ageing and Seniors
Supports mandated staff ratios, position unchanged

“Labor has been saying for a long time there needs to be more staff and better pay in aged care.

“Outbreaks of COVID-19 in aged care have clearly underscored the need to expand the aged care workforce.

“Sadly the Morrison Government has ignored report after report highlighting this issue.”

Ms Collins pointed out that Opposition Leader Anthony Albany recently committed to introducing “minimum staffing levels” in residential aged care, should the Labor party be elected to power.

Annie Butler, federal secretary, Australian Nursing and Midwifery Federation
Supports mandated staff ratios, position unchanged

“The ANMF has been a strong advocate of the need for mandated staffing ratios in aged care for many years. 

“Now, more than ever before, the COVID-19 outbreak and its devastating effects in aged care have demonstrated that mandating staff ratios must be an urgent priority, as part of any lasting reforms of the aged care sector. In fact until this occurs, safe and quality care across the sector cannot be guaranteed. Without mandated staffing ratios at the core, other reforms will continue to fall short.

“The ANMF, and a growing body of research around the world, has produced considerable evidence demonstrating the positive effects of the right number of the right types of staff, i.e. ratios, on the quality of care outcomes as well as evidence of the failures in care attributable to understaffing.

“The consequences of chronic understaffing across the sector, with respect to both insufficient numbers and skills of staff, have been brought into stark relief during the COVID-19 pandemic, with more than two-thirds of all deaths from COVID-19 in Australia occurring in aged care. 

“This tragic outcome is one of the worst in the world with regard to those living in nursing homes. 

“It’s distressing to consider that much of this suffering could have been prevented had action on staffing been taken earlier. 

“In Victoria, privately-run nursing homes, where providers set their own staff ratios based often on cost considerations rather than requirements to meet assessed care needs, have suffered substantially higher rates of COVID-19 than in Government facilities, which have mandated staff ratios. And importantly, mandated numbers of registered nurses on every shift. 

“Already, only 6 months into the pandemic American research is indicating the positive relationship between enough registered nurses in aged care and prevention of COVID-19. A Report published by the Journal of the American Medical Association found that in 4,000 nursing homes in eight US states, facilities with greater numbers of nurses experienced fewer cases of COVID-19.

“COVID-19 has only increased our resolve and determination to pursue mandated staff ratios across aged care. 

“The pandemic has stretched staff and resources even further and has made obvious to all the importance of having mandated, safe staffing levels and skills mix, to cope with intensified care demands.”

Patricia Sparrow, CEO, Aged and Community Services Australia
Does not support staff ratios or greater transparency, position unchanged

“There’s no doubt that aged care providers need to be able to employ more staff and provide the level of care the community expects.

“The staffing need is not just for more nurses, which staff ratios tend to focus on, but more staff overall, so while staff ratios aren’t necessarily the answer, we do definitely need more staff.

“Putting more staff in aged care homes will not only allow providers to offer a higher level of care, but can also be an economic driver and boost employment as Australia recovers from the coronavirus pandemic.

“Staffing needs to be based on resident needs and service models, and mandated ratios are too blunt a method to achieve that.

“Transparency is really important, but it also has to be meaningful. Potential residents and their friends and families need to be able to compare like for like services with similar resident profiles.

“The COVID-19 pandemic hasn’t changed ACSA’s views on staff ratios, but it has reinforced and further vindicated our view that aged care needs more staff and that requires funding reform and significant investment.”

Nicholas Brown, Acting CEO, The Aged Care Guild
Supports transparency in staff skills and numbers

The quality of care provided in aged care homes should first and foremost be based on the individual care requirements of each resident. There is no doubt the industry needs more workers, particularly as the baby boomer generation enters aged care.

However, rather than focusing only on the number of staff, other areas integral to the delivery of quality care also need to be considered. They include access to timely and high-quality staff training and development processes, recruitment processes that assess not only skillset but consider personal qualities of candidates, availability of end of life care and other specialised programs, as well as other support infrastructure that assist workers to do their job and ensure delivery of consistent, high-quality care.

Additionally, flexibility in numbers is important so that providers are able to adjust staffing rosters according to the needs of their residents and the occupancy levels of each home.

Currently, staff costs represent more than 80 per cent of care expenditure, however Government funding supports have not kept pace with increasing staff costs.

The Aged Care Guild support meaningful transparency. An appropriate, transparent and effective quality and safety system is good for senior Australians, for providers and for Government. We must ensure information is meaningful and gives clarity on the quality of care provided, assisting senior Australians and their families to make informed decisions when it comes to aged care.

The aged care sector is committed to the necessary reform, but we cannot do it alone; real change means necessary and structural reform from Government. This means taking lessons learnt from the Royal Commission and COVID-19 to develop a long-term and consumer-centred plan for reform, to ensure aged care workers are acknowledged and valued and senior Australians receive the quality of care they need and deserve.

Image: Jacob Lund, iStock.

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